Basic Information
| Provider Information | |||||||||
| NPI: | 1710980511 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPEN MRI OF FEDERAL WAY, L.L.C. | ||||||||
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| OtherOrganizationName: | NYDIC OPEN MRI OF AMERICA-FEDERAL WAY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARAGON DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MONTVALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076451718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015738080 | ||||||||
| FaxNumber: | 2017754306 | ||||||||
| Practice Location | |||||||||
| Address1: | 33301 9TH AVE S | ||||||||
| Address2: | STE 105 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980032600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539528833 | ||||||||
| FaxNumber: | 2539528866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUCHWALTER | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2015738080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | X | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QM1200X | X | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
| ID | Type | State | Issuer | Description | 16-50184 | 01 | WA | UNITED HEALTHCARE | OTHER | 1069170 | 01 | WA | FIRST HEALTH NETWORK | OTHER | 115994 | 01 | WA | BWC | OTHER | 5574678 | 01 | WA | AETNA US HEALTHCARE | OTHER | 8922466 | 01 | WA | WA WC-CRIME VICTIMS | OTHER | OP8664 | 01 | WA | REGENCE BS | OTHER | 115994 | 01 | WA | WASHINGTON WC | OTHER | 2504 | 01 | WA | MEDFOCUS | OTHER | 7085962 | 05 | WA | MEDICAID | A-70849 | 01 | WA | MULTIPLAN | OTHER |